There are many possible causes of lower back pain (LBP) and associated pain, which might require further medical intervention to diagnose, manage or resolve. However for many people, the answer as to why they are experiencing ongoing pain and discomfort in the lower back, and surrounding areas, might be found by looking more holistically and examining postural and functional dynamic control of the whole body.
Some common functional causes for lower back pain include:
Postural abnormalities
Previous or current injuries elsewhere in the body and associated compensation
Weakness in core or hip muscles - more on this later!
Referred pain from trigger points in iliopsoas (hip flexors)
Referral pain from piriformis entrapment or tightness
Decreased lower extremity and lumbar (back) flexibility
Poor hamstring strength
Pelvic rotation or tilt; especially an anteriorly tilted pelvis
Poor dynamic control and co-ordination of the limbs with the core
Engaging in a new activity
A seemingly innocuous movement with a momentary dip in control - an "unguarded movement"
Click here for an excellent description of the causes of lower back pain, and why it hurts so much, written by Rupert Clements (Chiropractor at C1 Chiropractic Health Centre) .
If you are reading this because you are currently suffering with LBP, I very much hope that you consider taking a two pronged musculoskeletal approach to its resolution, by heeding the Chiropractic treatment advice referred to above, combined with the following soft tissue information and guidance on stretching and strengthening.
Here, I am going to look at the muscles that play an enormous role in keeping you moving and stable - The Lumbopelvic Hip Complex (LPHC)- and their role in keeping you free from lower back pain.
The lumbopelvic hip complex has a total of 29 muscles that attach to it.
Some of the major muscles that attach are the hamstrings, gluteals, piriformis, tensor fascia latae, ITB (iliotibial band), adductors, abdominals (rectus abdominis, transverse abdominis, and internal & external obliques) and lumbar muscles to name a few.
This complex acts as a transition from your lower to upper body by serving to transmit forces that are generated. For this reason, it needs to be stable so that it doesn’t cause different parts of the body to overcompensate, which can result in injury, and of course pain.
The core is considered the integral link in the kinetic chain. All movements incorporate the transfer of energy from one segment to the next in the kinetic chain model. Whatever the skill or movement being performed, it is paramount that individuals have the correct postural control when performing movement skills. If an individual lacks postural control, they will not be able to transfer the optimal energy to the arms and legs, and ultimately will be susceptible to injury, through compensations made in an attempt to make up for the lack of core power and stability.
What this means is that in order to keep the lower back stable during movement, all of the LPHC muscles need to be strong as well as flexible, to provide the mobility and stability required. Without this balance of muscular strength and flexibility, you are at risk of developing postural deviations, leading to potential injury or dysfunction, and ultimately, lower back pain. It is therefore essential to combine core training with stretching multiple muscles in multi-directions, to prevent or recover from injury.
One of the most common postural deviations encountered is excessive anterior pelvic tilt (APT). Some visual cues of anterior pelvic tilt are:
A forward tipped pelvis
Increased lower back curve (sway back)
A “bulging” (not necessarily fat) abdomen
This pattern is characterised by:
overextension of the lumbar spine,
lack of glute involvement, and
quadricep tightness and low-back dominance.
Having a dynamic postural assessment with a physical therapist is advisable if you are experiencing ongoing back pain. Upon assessment, the therapist will look for static and dynamic visual cues and deviances from ideal anatomical posture and movement. If it is apparent that you are experiencing an anteriorly tilted pelvis, further signs might also be evident; your hip flexors might be stiff or tight, and you might have poor core strength and inhibited gluteal control and strength.
Signs of excessive anterior pelvic tilt are increasingly evident in people in our modern world, with it being especially common among females, especially those who are or have been pregnant.
Its primary causes in today's world include a sedentary lifestyle (e.g. prolonged sitting), poor movement patterns and posture, and genetic predispositions.
Sitting and performing tasks with poor posture for extended periods of time lead to shortening of the hip flexors, increased tension on the lower back, and gluteal atrophy/wastage. These problems develop over time, and once present, performing simple daily activities such as tying one’s shoes or reaching around to put on a coat, can cause significant pain.
Stretches & Exercises to Support Lumbar and Hip Control
To maintain optimum function of the gluteal muscles, the piriformis and ITB; (the ITB is the fascia that gets taught, originating from the top of the outside of the hip, down the outside of the thigh and attaching just below the knee); maintenance stretching should be incorporated into daily routines, each time aiming to take the stretched fascia a little further without causing pain.
Here are a few really useful exercises and stretches of the muscles that can become tight and associated with lower back pain.
Pelvic Tilts
Pelvic tilts are an exercise comprised of very subtle spinal movements that strengthen the support muscles around the low back, particularly the abdominals. They are a good preliminary exercise for those seeking low back pain relief, and they feel great because they give your back a little massage.
Pelvic tilts can be done lying on the floor (supine pelvic tilts), standing with the back to a wall, on all fours, or seated on an exercise ball. The standing version is a bit more difficult, but it is a good option for pregnant women who are not comfortable on their backs or people who can't lie on the floor.
You can do it on a firm bed, exercise mat, or on the floor if you are comfortable.
Lie on your back with the knees bent and the soles of the feet on the floor. This is your neutral position, with the natural curve of the lumbar spine causing the low back to be slightly elevated from the floor.
On an exhale, gently rock your hips towards your face. Your butt will not actually leave the floor, but you will feel your low back press into the floor. You are essentially taking the curve out of the low back. Think of the pelvis as a bowl of water. When you do the pelvic tilt, the water would be spilling towards your belly.
After a few seconds, inhale and return to your neutral position.
Repeat this movement five to 10 times
Knee to Chest Stretch
The knee-to-chest stretch is a great way to relieve back pain after a long day at work or a workout mishap. HOWEVER, you may find lying on your back with your legs extended too uncomfortable. If so, do not attempt this stretch until you are more mobile.
This stretch can be done in your bed, so there is no excuse not to do it twice a day — when you wake up and right before you go to bed.
Lie on your back with you legs extended
Gently bend your right knee into your chest. Clasp your hands in front of your shin and gently pull down to increase the stretch. Release any tension in your shoulders and neck.
Keep your left leg relaxed in a comfortable position.
Hold for 30 seconds and then repeat with the left knee bent.
Kneeling Quadriceps and Hip Flexor Stretch
The quadriceps and hip flexors can be tight and overactive. This stretch helps to loosen them up. To perform this stretch, kneel on the ground with one leg forward, knee bent, and your foot flat on the floor. You might like to place a cushion beneath the kneeling knee for comfort. Make sure that your front thigh is parallel to the floor at 90 degrees to your shin. Squeeze your gluteal muscle as you push your pelvis forward. Hold this for 30 seconds then go back to your first position. Repeat on your other leg. Continue alternating as many times as you want. Use this slow, hip flexor and quad stretch before attempting the glute activation exercises.
Perform a dynamic version of this during your warm up before running and this static stretch later in the day.
Supine Trunk Twist
This is a trunk mobility exercise and should be performed only within pain free range. You might like to start with just bringing your knees to your chest and rolling them around in circles in each direction first.
To enjoy the full range of motion your hip joint has to offer, it's important to keep the outside of the hip and thigh flexible. This variation on the supine twist really stretches that area. Lying on your back, extend your arms out to your sides. Bend your knees, and cross your right leg over your left. Slowly rotate your knees to the right, allowing them to come to the floor. It's OK if your left shoulder comes off the floor a little. Hold for 20 to 30 seconds. Then, slowly bring your knees back to centre.Reverse directions and twist to the left. Repeat as needed. Use your breath to relax into the rotation; exhaling as you lower your knees to the floor, and being careful to engage your lower abdominals as you bring the knees back to the middle.
Spinal Rotation
Seated spinal rotations are another great way to loosen up your spine and add movement to the joints in your lower back. There are many types of spinal twists, but here are the steps to a seated spinal rotation that can easily be adapted for your desk chair.
Begin seated on your mat with your legs extended in front of you.
Keep your left leg extended and bend your right knee and cross your right foot over your left knee. Plant it on the floor so your right ankle is next to your left knee.
Reach your right arm behind you and place your palm on the floor. Then bend your left elbow and cross it over the outer side of your right knee. Keep your elbow bent, gripping your thigh for stability.
Continue pressing your left arm into your right knee, and use each inhale to lengthen the spine and each exhale to rotate further to the right.
Stay here for five or more breaths. Then release the twist, straighten your legs out in front of you, and do this pose with your left knee pointing up.
Piriformis & Glute Stretch
Lie on your back with both legs in the air. Place your left ankle on your right thigh just above your knee. See the shape of the number four? It's there, just upside down.
Clasp your hands around your left thigh and slowly pull your thigh toward your chest. You should feel a stretch on the outside of your left hip. Hold for 20 to 30 seconds, then repeat on the other side.
Alternatively, you might prefer the pigeon pose stretch.
Begin in a kneeling on all fours position
Straighten one leg out behind you, and draw the other leg across and in front of the mid line of your body.
Slide the hips backwards, and fold your upper body forwards and down towards the floor.
You should aim to keep the pelvis parallel to the floor.
Your general hip mobility will determine how far you are able to take this stretch, but it should be felt at the upper, outer side of your glutes of the forward leg.
The Glute Bridge/ Single Leg Glute Bridge
This is the easiest way to get your glutes firing as well as activating your core. The movement is small and targeted, so go slowly and you will feel your glutes "waking up."
When you feel you have mastered the bridge, try isolating one side of your glutes, by performing a single leg bridge.
Raise the hips, to the same height so you have a straight line from the shoulders (which should be nicely relaxed), through your hips and to your knees), while lifting the other leg either filly extended or with the knee bent and above the hips..
Hold the position, or oerform gentle small pulses for 8 reps before lowering the hips back to the floor again. Repeat on each side 6-8 times.
Supported Side Plank
Lie on your side supporting your upper body with forearm. To begin with, perform this exercise with both knees bent, then as you gain strength and confidence, progress to extending just the top leg, and then both. Carefully raise your hips to the ceiling (if you are comfortable holding this for 20 + secs, extend the top leg). Maintain a straight line through your torso and hips to your feet, while lifting the hips upwards. Either hold the position for 20 secs+ or lift & lower for 12 reps each
Lower Ab Activation
Lie on your back with a neutral spine and feet flat on the floor. Inhale through your nose, and as you exhale through your mouth, draw your belly button downwards to you spine, flattening your back.
Inhale and exhale again, this time raising your left foot off the floor to bring you left knee to right angles above the left hip.
Place both hands on to the left knee, whilst maintaining a neutral spine.
Now, (while continuing to breathe naturally) apply some pressure downwards with both hands in to the knee, while drawing the knee upwards in to the hands, thus engaging the lower abdominals. You should feel quite a strong contraction of the lower abdominal region. Hold for 5 seconds (maintain regular and gentle breathing).
Lower the left leg, to the floor regain a neutral spine and repeat with the right leg.
Repeat this 4 times on each side
To progress this, bring both knees up to above the hips at right angles with your palms pressed into your thighs just above your knees.
Pull your abs to your spine, keeping your ribs and pelvis still as you lengthen your right arm and leg out until they are almost parallel to the floor. Keep your torso and spine completely stable as the arm and leg move.
NB: Both the lower ab activation and the dead bug should only be performed at this level when you are able to hold your knees at 90 degrees above the hips while maintaining a flat/neutral back. If you feel any arching of the lower back, then place both feet on the floor and start with heel slides first.
Dead Bug
This exercise is a progression of the lower ab activation exercise, and may be performed only when movement of the back is pain free, but it is an excellent core stability exercise.
Lie on your back with a neutral spine and your hips and knees at right angles with your palms pressed into your thighs just above your knees.
Always ensure you are pulling your abs to your spine, keeping your ribs and pelvis still as you lengthen your right arm and leg out until they are almost parallel to the floor. Keep your torso and spine completely stable as the arm and leg move.
Return to the starting position, and repeat on the left side to complete one rep.
Superman / Bird Dog
A variation of the Dead Bug exercise is the Superman or Bird-Dog
It’s a classic core exercise that emphasizes
core and lower back strength. However, it’s not just your core that gets worked. You’ll also improve:
Your balance and ability to stabilize
Your arm and shoulder blade/rotator cuff muscles
Your glutes
Your hamstrings (the muscles at the back of your leg)
Start out on hands and knees with the hands directly under the shoulders and the knees directly under the hips. Relax the low back to a neutral position. It is important to keep the body in a straight line while lifting your legs. Start out by lifting one leg slowly and holding the position of the low back. If you feel like you are leaning outwards on to the supporting leg side, re-align yourself by bringing the supporting hand on the same side (as the kneeling leg) behind your back. This will encourage you to regain the correct centre of gravity.
To progress this, you might like to simultaneously reach out the opposite arm, (to the leg that is being extended) forward overhead. Make sure you maintain a neutral low back position with your pelvis parallel to the floor.
Now return that arm and leg to the floor and repeat with the opposite arm and leg. Repeat this 10 times on each side.
N.B.
If you feel any pain in the lower back performing this exercise, regress the movement so that:
you keep both knees on the floor and start with just the overhead arm extension OR
Return to the lower abdominal activation and heel slide, ensuring you engage with the lower abdominals first and maintain a neutral spine (no arching of the lower back)
As with all exercises for back pain, you may find that some days you feel more or less able to perform them, so be guided by the level of your mobility and comfort, but ALWAYS ensure that you are engaging the core throughout the exercises.